QA Investigation Results

Pennsylvania Department of Health
ASSOCIATES SURGERY CENTERS, L.L.C.
Health Inspection Results
ASSOCIATES SURGERY CENTERS, L.L.C.
Health Inspection Results For:


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Initial Comments:

This report is the result of a full Medicare recertification survey conducted on December 6 and 7, 2018, at Associates Surgery Center. It was determined that the facility was in compliance with the requirements of 42 CFR, Title 42, Part 416 - Conditions of Participation for Ambulatory Surgical Centers.





Plan of Correction:




Initial Comments:

This report is the result of a State licensure survey conducted on December 6 and 7, 2018, at Associates Surgery Center. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.





Plan of Correction:




553.25 (1-6) LICENSURE
Discharge Criteria

Name - Component - 00
553.25 Discharge Criteria

A patient may only be discharged from an ASF if the following physical status criteria are met:
(1) Vital signs. Blood pressure, heart rate, temperature and respiratory rate are within the normal range for the patient's age or at preoperative levels for that patient.
(2) Activity. The patient has regained preoperative mobility without assistance or syncope, or function at his usual level considering limitations imposed by the surgical procedure.
(3) Mental status. The patient is awake, alert or functions at his preoperative mental status.
(4) Pain. The patient's pain can be effectively controlled with medication.
(5) Bleeding. Bleeding is controlled and consistent with that expected from the surgical procedure.
(6) Nausea/vomiting. Minimal nausea or vomiting is controlled and consistent with that expected from the surgical procedure.

Observations:

Based on review of facility documents, medical records (MR), and interview with staff, it was determined the facility failed to document physical status criteria for three of ten medical records reviewed (MR1, MR2, MR3).

Findings include:

Review of facility policy, "Discharge Criteria," last reviewed January 22, 2018, revealed, "Policy: Patients will not be discharged until they possess the same mental facilities as prior to surgery. ... 2. Each patient's general overall status will be observed to include the documentation of mental status (conscious and coherent condition), adverse symptoms (pain, cough, dizziness, nausea, etc.), patient color, and condition of eye patch, if applicable, condition of dressing, if applicable and presence of bleeding and/or drainage. 3. Vital signs will be taken and recorded. ... 4. Nausea/vomiting ... 5. Activity ... 6. Mental status ... 7. Pain ... 8. Bleeding ... .

1. Review of MR1, MR2, MR3, revealed no documentation that physical status criteria, vital signs, activity, mental status, pain, or bleeding was met prior to discharge.

2. Interview with EMP1, on December 7, 2018, at approximately 1:00 PM confirmed the above findings.





Plan of Correction:

The facility will revise our medical records listed as MR1, MR2 and MR3 on the POC. The revisions will incorporate discharge criteria for all procedures including YAG and SLT lasers. Discharge criteria will include documentation regarding physical status criteria, vital signs, activity, mental status, pain, bleeding, nausea or vomiting. The new forms will be revised and implemented no later than Jan. 15, 2019. Staff education will be conducted prior to using the new forms. Follow-up monitoring will occur on an ongoing basis.